Advanced Cardiac Life Support

EMERGENCY CARDIAC CARE

Assess Responsiveness
Unresponsive
Call for code team and Defibrillator
Assess breathing (open the airway, look,
listen and feel for breathing)
If Not Breathing,
give two slow breaths.
Assess Circulation
PULSE

NO PULSE

Give oxygen by bag mask

Secure IV access
Determine probable etiology of arrest
based on history, physical exam, cardiac
monitor, vital signs, and 12 lead ECG.

If witnessed arrest, give

precordial thump and
check pulse. If absent,
continue CPR
Ventricular
fibrillation/tachycardia
(VT/VF) present on
monitor?

Hypotension/shock,
acute pulmonary
edema.
Go to fig 8

YES

NO
Intubate
Confirm tube placement
Determine rhythm and
cause.

Arrhythmia

Bradycardia
Go to Fig 5

Initiate CPR

Tachycardia
Go to Fig 6

VT/VF
Go to Fig 2

Electrical Activity?

YES
Pulseless electrical activity
Go to Fig 3

NO
Asystole
Go to Fig 4

Fig 1 - Algorithm for Adult Emergency Cardiac Care

VENTRICULAR FIBRILLATION AND PULSELESS

VENTRICULAR TACHYCARDIA

Assess Airway, Breathing, Circulation, Differential Diagnosis

Administer CPR until defibrillator is ready (precordial thump if witnessed arrest)
Ventricular Fibrillation or Tachycardia present on defibrillator
Defibrillate immediately, up to 3 times at 200 J, 200-300 J, 360 J.
Do not delay defibrillation
Check pulse and Rhythm
Persistent or
recurrent VF/VT

Continue CPR
Epinephrine 1 mg
IV push, repeat
q3-5min or 2 mg in
10 ml NS via ET tube
q3-5min or
Vasopressin 40 U IVP x
1 dose only
Defibrillate 360 J

Continue CPR
Secure IV access
Intubate if no response
Return of
spontaneous
circulation

Pulseless Electrical
Activity
Go to Fig 3

Asystole
Go to Fig 4

Monitor vital signs

Support airway
Support breathing
Provide medications appropriate for blood
pressure, heart rate, and rhythm

Amiodarone (Cordarone) 300 mg IVP or

Lidocaine 1.5 mg/kg IVP, and repeat q3-5 min, up to total max of 3 mg/kg or
Magnesium sulfate (if Torsade de pointes or hypomagnesemic) 2 gms IVP or
Procainamide (if above are ineffective) 30 mg/min IV infusion to max 17 mg/kg

Continue CPR
Defibrillate 360 J, 30-60 seconds after each dose of medication

Repeat amiodarone (Cordarone) 150 mg IVP prn (if reurrent VF/VT) ,up to max
cumulative dose of 2200 mg in 24 hours

Continue CPR. Administer sodium bicarbonate 1 mEq/kg IVP if long arrest period
Repeat pattern of drug-shock, drug-shock

Note: Epinephrine, lidocaine, atropine may be given via endotracheal tube at

2-2.5 times the IV dose. Dilute in 10 cc of saline.
After each intravenous dose, give 20-30 mL bolus of IV fluid and elevate
extremity.

Fig 2 - Ventricular Fibrillation and Pulseless Ventricular Tachycardia

PULSELESS ELECTRICAL ACTIVITY

Pulseless Electrical Activity Includes:

Electromechanical dissociation (EMD)
Pseudo-EMD
Idioventricular rhythms
Ventricular escape rhythms
Bradyasystolic rhythms
Postdefibrillation idioventricular rhythms
Initiate CPR, secure IV access, intubate, assess pulse.

Determine differential diagnosis and treat underlying cause:

Hypoxia (ventilate)
Hypovolemia (infuse volume)
Pericardial tamponade (perform pericardiocentesis)
Tension pneumothorax (perform needle decompression)
Pulmonary embolism (thrombectomy, thrombolytics)
Drug overdose with tricyclics, digoxin, beta, or calcium blockers
Hyperkalemia or hypokalemia
Acidosis (give bicarbonate)
Myocardial infarction (thrombolytics)
Hypothemia (active rewarming)

Epinephrine 1.0 mg IV bolus q3-5 min, or high dose

epinephrine 0.1 mg/kg IV push q3-5 min; may give via
ET tube.
Continue CPR

If bradycardia (<60 beats/min), give atroprine 1 mg IV, q3-5

min, up to total of 0.04 mg/kg
Consider bicarbonate, 1 mEq/kg IV (1-2 amp, 44 mEq/amp),
if hyperkalemia or other indications.

Fig 3 - Pulseless Electrical Activity

ASYSTOLE

Continue CPR. Confirm asystole by

repositioning paddles or by checking 2 leads.
Intubate and secure IV access.

Consider underlying cause, such as hypoxia,

hyperkalemia, hypokalemia, acidosis, drug
overdose, hypothermia. myocardial infarction.

Consider transcutaneous pacing (TCP)

Epinephrine 1.0 mg IV push, repeat every 3-5 min;

may give by ET tube; high dose epinephrine 0.1
mg/kg IV push q5min (1:1000 sln).

Atropine 1 mg IV, repeat q3-5min up to a total of

0.04 mg/kg; may give via ET tube.

Consider bicarbonate 1 mEq/kg (1-2 amp) if

hyperkalemia, acidosis, tricyclic overdose.
Consider termination of efforts.

Fig 4 - Asystole

BRADYCARDIA

Assess Airway, Breathing, Circulation,

Differential Diagnosis
Secure airway and give oxygen
Secure IV access
Attach monitor, pulse oximeter and
automatic sphygmomanometer

Assess vital signs

Review history
Perform brief physical exam
Order 12-lead ECG

Too slow (<60 beats/min)

Bradycardia (<60 beats/min)

Serious Signs or Symptoms?

Yes

No
Type II second degree AV heart
block or third degree AV heart
block?

If type II second or 3rd degree heart block,

wide complex escape beats, MI/ischemia,
denervated heart (transplant),new bundle
branch block: Initiate Pacing(transcutanous
or venous)
If type I second degree heart block, give
atropine 0.5-1.0 mg IV, repeat q5min, then
initiate pacing if bradycardia.
Dopamine 5-20 mcg/kg per min IV infusion
Epinephrine 2-10 mcg/min IV infusion
Isoproterenol 2-10 mcg/min IV infusion

No

Observe

Yes

Consider transcutaneous pacing or transvenous

pacing.

Fig 5 - Bradycardia (with patient not in cardiac arrest).

Assess Airway, Breathing, Circulation, Differential Diagnosis

Assess Vitals, Secure Airway
Review history and examine patient.
Give 100% oxygen, secure IV access.
Attach ECG monitor, pulse oximeter, blood pressure monitor.
Order 12-lead ECG, portable chest x-ray.

TACHYCARDIA

UNSTABLE, with serious signs or symptoms?

Unstable includes, hypotension, heart failure, chest pain, myocardial
infarction, decreased mental status, dyspnea

IMMEDIATE CARDIOVERSION
Atrial flutter 50 J, paroxysmal supraventricular tachycardia
50 J, atrial fibrillation 100 J, monomorphic ventricular
tachycardia100 J, polymorphic V tach 200 J.
Yes
Premedicate with midazolam (Versed) 2-5 mg IVP when
possible.

No or borderline
Atrial fibrillation
Atrial flutter

Determine Etiology: Hypoxia, ischemia,

MI, pulmonary embolus,
hyperthyroidism, electrolyte abnomality,
theophylline, inotropes.

Paroxysmal
supraventricular
narrow complex
tachycardia
(PSVT)

Vagal maneuvers:
Carotid sinus
massage if no
bruits

Control Rate: Diltiazem,verapamil, digoxin

esmolol, metoprolol

Cardioversion of atrial fibrillation to sinus rhythm:

If less than 2 days and rate controlled:
Procainamide or amiodarone, followed by
cardioversion
If more than 2 days: Coumadin for 3 weeks;
control rate, start antiarrythmic agent, then
electrical cardioversion.

Fig 6 Tachycardia

Adenosine
6 mg, rapid IV
push over 1-3 sec
1-2 min

Wide-complex
tachycardia of
uncertain type

Ventricular
tachycardia (VT)
with pulse
present

If uncertain if V tach,
give Adenosine 6
mg rapid IV push
over 1-3 sec
1-2 min
Adenosine
12 mg, rapid IV
push over 1-3 sec
(may repeat once
in 1-2 min)

Amiodarone 150300 mg IV over 1020 min

Torsade de pointes
(polymorphic VT)
with pulse present

Correct underlying
cause: Hypokalemia, drug overdose (tricyclic,
phenothiazine,
antiarrhythmic
class Ia, Ic, III)

Adenosine 12 mg, rapid IV

push over 1-3 seconds (may
repeat once in 1-2 min); max
total 30 mg

Lidocaine
1-1.5 mg/kg IV push.
Repeat
mg/kg IVP q5-10min
to max total 3 mg/kg

Overdrive
(cutaneous or venous)
Isoproterenol 2-20 mcg/min
OR
Phenytoin 15 mg/kg IV at 50
mg/min OR
Lidocaine 1.0-1.5 mg/kg IVP
Cardioversion 200 J

Complex
Wide

Narrow
Blood Pressure ?

Normal or elevated pressure

Verapamil
2.5-5 mg IV
15-30 min
Verapamil
5-10 mg IV

Consider
Digoxin
Beta
Diltiazem
Overdrive
pacing

Low-unstable

If
syndrome,
(Cordarone) 150-300 mg IV
over 10-20 min

Procainamide
20-30 mg/min, max total 17 mg/kg;
followed by 2-4 mg/min
If WPW, avoid adenosine, betablockers,
digoxin

Synchronized cardioversion 100 J

Fig 6 - Tachycardia

Magnesium 2-4 gm IV
over 5-10 min

Procainamide
mg/min IV to max
total 17 mg/kg

Lidocaine 1.0-1.5 mg/kg IVP

STABLE TACHYCARDIA
Stable tachycardia with serious signs and
symptoms related to the tachycardia. Patient
not in cardiac arrest.

If ventricular rate is >150 beats/min, prepare for immediate cardioversion.

Treatment of Stable Patients is based on Arrhythmia Type :
Ventricular Tachycardia:
Procainamide (Pronestyl) 30 mg/min IV, up to a total max of 17 mg/kg,
or
Amiodarone (Cordarone) 150-300 mg IV over 10-20 min, or
Lidocaine 0.75 mg/kg. Procainamide should be avoided if ejection
fraction is <40%.
Paroxysmal Supraventricular Tachycardia: Carotid sinus pressure (if
bruits absent), then adenosine 6 mg rapid IVP, followed by 12 mg rapid
IVP x 2 doses to max total 30 mg. If no response, verapamil 2.5-5.0 mg
IVP; may repeat dose with 5-10 mg IVP if adequate blood pressure; or
Esmolol 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion, and
titrate up to 200 mcg/kg/min IV infusion.
Atrial Fibrillation/Flutter:
Ejection fraction $40%: Diltiazem (Cardiazem) 0.25 mg/kg IV over 2
min; may repeat 0.35 mg/kg IV over 2 min prn x 1 to control rate. Then
give procainamide (Pronestyl) 30 mg/min IV infusion, up to a total max
of 17 mg/kg
Ejection fraction <40%: Digoxin 0.5 mg IVP, then 0.25 mg IVP q4h x 2
to control rate. Then give amiodarone (Cordarone) 150-300 mg IV over
10-20 min.

Check oxygen saturation, suction device,

intubation equipment. Secure IV access

Premedicate whenever possible with Midazolam (Versed)

2-5 mg IVP or sodium pentothal 2 mg/kg rapid IVP

Synchronized cardioversion
Atrial flutter
50 J
PSVT
50 J
Atrial fibrillation
100 J
Monomorphic V-tach 100 J
Polymorphic V tach 200 J
Fig 7 - Stable Tachycardia (not in cardiac arrest)

HYPOTENSION, SHOCK, AND ACUTE PULMONARY EDEMA

Signs and symptoms of congestive heart failure, acute pulmonary edema.
Assess ABCD's, secure airway, administer oxygen; secure IV access. Monitor ECG, pulse oximeter,
blood pressure, order 12-lead ECG, portable chest X-ray
Check vital signs, review history, and examine patient. Determine differential diagnosis.

Determine underlying cause

Administer Fluids, Blood

Consider vasopressors
Apply hemostasis; treat
underlying problem

Bradycardia or Tachycardia

Pump Failure

Hypovolemia

Determine blood pressure

Systolic BP
<70 mm Hg

Norepinephrine 0.530 mcg/min IV or

Dopamine 5-20
mcg/kg per min

Systolic BP
70-100 mm Hg

Dopamine 2.5-20
mcg/kg per min IV
(add norepinephrine
if dopamine is >20
mcg/kg per min)

Fig 8 - Hypotension, Shock, and Acute Pulmonary Edema

Systolic BP >100 mm Hg
and diastolic BP normal

Dobutamine2.0-20
mcg/kg per min IV
Furosemide IV 0.5-1.0 mg/kg
Morphine IV 1-3 mg
Nitroglycerin SL 0.4 mg tab
q3-5min x3
Oxygen

Bradycardia Tachycardia
Go to Fig 5 Go to Fig 6
Diastolic BP >110 mm Hg

If ischemia and hypertension:

Nitroglycerin10-20
IV, and titrate to effect and/or
Nitroprusside 0.1-5.0
mcg/kg/min IV